Product Review - Home Based Care

When someone we love is injured, disabled, convalescing, frail or terminally ill
we want only the best...

If you are fortunate enough to be on a medical scheme ask them about HBC benefits and what is required for them to cover it. In most cases the agency needs to be a registered provider (with a Board of Healthcare Funders registration number) and invoices must reflect the correct tariff and ICD 10 codes. Nursing staff providing Formal HBC must be registered with the South African Nursing Council.

Many HBC costs are tax deductible and we have summarised this below. For detailed information please refer to the Rolling Inspiration Tax Benefits and Deductions booklet available to subscribers on our website, www.rollinginspiration.co.za.

Tax Deductions

A taxpayer / spouse / child who has a disability (in accordance with criteria prescribed by SARS) can claim qualifying expenses as a deduction from his or her income (inclusive of VAT) in full.

A taxpayer / spouse / child / dependant who has a physical impairment that is not a disability can claim qualifying expenses if the amount exceeds 7,5% of the taxpayer's taxable income.

Qualifying Expenses

Special services to assist, guide, care for a person with a physical impairment or disability, regardless of where services are rendered (e.g. home, nursing home, retirement home etc). This includes nursing services, special care, chauffeur services, salaries to employees and fees for professional services, e.g. nursing homes. For example: When employing someone, primarily for care, who occasionally assists with house keeping activities, their salary will qualify. When employing someone primarily for housekeeping, who occasionally provides care, their salary will not qualify.

Training for workers and / or family and related expenditure.

Special education and training of a person with adisability to cope with the disability, rehabilitation and educational institutions for specific disabilities.

What is Home-based care?

The World Health Organisation defines HBC as "health service provision (formal and informal) in the home to promote, restore and maintain the maximum level of comfort, function and health."

HBC is recommended when a person requiring care (the client) would like to remain in their home environment but requires additional healthcare that the family are not able to provide. HBC may be required for short periods e.g. recovery from surgery or bedsores; or for a medium term (to assist with the transition from hospital); or full-timelong-term.

What are the advantages?

The client remains in a familiar environment and participates in daily family routines. This maintains daily contact and a healthy family relationship.

The care worker has the knowledge and experience to deal with the client's medical needs and assist with improving functional independence.

HBC carers provide healthcare services so that family members can fulfil their role of parent, spouse, partner or sibling - as opposed to being the primary caregiver.

HBC can provide care when family members are away.

The client feels less of a burden on the family and is able to become more independent.

Which services do I need?

This depends on the needs ofthe client - for example, companionship may be required when there is no-one at home during the day, the family live far away or the client is unable to leave the home. If the client is on a ventilator then medical care is essential, along with training on warning signs and what to do in an emergency.

Your medical team can best provide you with information on the level of care required. If you are still in hospital your functional and lifestyle needs may change as you settle into your daily routine at home.

Your rehab unit will be able to give you the contact details of agencies and individual healthcare service providers. There are also many training programmes that assist in placing HB Carers. You need to decide whether to use an agency, train someone or take onan independent HB carer. Remember to ask independents questions such as how they will cope if the service needs extending e.g. extra hours or nights, and what will happen if the carer is ill or unable to come to work. Associations such as APD and QASA provide short-term training in basic HBC for domestic workers and family members (see below).

In general, the more training HB carers have, the higher the cost to you. Hiring a cheaper, untrained and less experienced carer may cost you in the long run, but If they do not know how to lift, or assist with moving, a client this could result in additional surgery and / or rehabilitation costs!

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It is very important to understand the risks associated with Home Based Care.

HB carers without nursing qualifications are NOT regulated by a professional council, nor are there any regulated practice standards. This makes the quality of service offerings erratic, and problematic in a malpractice case.

Since these HB carers are not regulated by acouncil, many practice without accredited training.

Clients MUST ensure that HB Carers haveaccredited training suitable to the tasks you require of them

Most agencies offer a needs assessment to match the needs of the family with the correct level of care.This is essential! The relationship begins here - make sure you communicate allof your expectations. Give the agency the chance to say "No" if they feel they cannot meet your requirements.

Discuss the level of care required with your rehab team as they can guide you on the medical and functional needs. If the client has a rehab programme the HB carer should meetthe rehab team so that instructions and methods of the home programme can be given (and demonstrated) directly to the HB Carer. Ask your HB carer to repeat the programme in front of the rehab team to ensure they understood.

Types of HBC

Integrated Service HBC - This is a service provider who might have no formal medical training. They assist in contacting healthcare providers for medical advice and as a resource when looking for specialised or adapted equipment /services. Hospice is a good example of an Integrated HBC Service provider. They would not provide daily services but could visit once or twice a week to assist you with essential advice and support.

Informal HBC - These workers can perform basic Activities of Daily Living tasks (ADL) but have limited skills.They often have no formal training and, if they have been trained, it is not a registered qualification. Informal care workers are cost effective but there are risks associated with the lack of training. They may also not be trained in Emergency Care such as CPR and First Aid and it would be recommended to send them on an accredited two-day course. They can deal with simple disabilitiesand are good options if there is a family member who can oversee their work.

Formal HBC - These are health care professionals with formal training innursing, ancillary healthcare or community healthcare and are better equipped to cope with more complicated cases. They can perform a range of duties depending on the extent of their clinical training. They often have the skills and knowledge to provide physical and emotional support for a range of impairments and disabilities and will be more expensive than Informal HBC. Make sure that the carer has a qualification from an accredited training institute and that they have emergency care training to deal with basic medical emergencies should you require it.

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Newer agencies have been unable to register witht he South African Nursing Council / National Department of Health as there is a moratorium in place. They have also been unable to register with the Board of Healthcare Funders as is required by medical schemes. The Department of Healthand the South African Nursing Council are looking into the registration issue, aswell as the regulating of nursing agencies.

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Levels of Care

There are four basic categories of care:

Medical Care - these are services that require medical and / or First Aid training. They may include, but are not limited to: client observation, reading and understanding vital signs, wound care, bedsore prevention, managing seizures, medication administration, bladder / bowelmanagement, managing oxygen masks, managing a ventilator, managing a Peg Tube and knowing what to do if there are power outages.

Functional Care - these are services that assist the client with day-to-day functions such as: feeding; personal hygiene (bathing,showering, bed baths); lifting; moving; turning; managing a fall; pillows, bedlinen and bed controls; dressing, toileting, grooming and managing mobility aids. This does not necessarily require medical training but it is essential that carers have received training from a registered professional on how to perform them. They should receive specific training for the client's specific needs and conditions.

Rehabilitative or Health Promotive Care - this is usually taught to HB carers by an allied health worker or therapy team. Although medical knowledge is not needed, training is essential. Each client has specific precautions related to their condition and these need to be taught to the careworker as well as emergency protocols. Tasks could include: home programmes e.g. exercise and stimulation, accompanying the client to support groups, managing aggressive outbursts, assisting with outings, communicating with amulti-disciplinary team, bedsore prevention.

Comfort and Lifestyle Services - services could includecompanionship, making and accompanying to appointments, maintaining a hygienicliving space, meal planning and preparation, technology (phone, TV etc), shopping, reading out newspapers and letters as well as awareness of the client's spiritual needs.

Challenges and Solutions

When someone else is taking care of our loved one there will always be things that they do that are "wrong" or "different." It is difficult for family members to let carers find their way. It is also difficult to adjust to having an outsider in your home, as privacy is reduced.

It is important to establish communication channels and responsibilities from the beginning. When the boundaries are well established and respected (and there is an opportunity to talk about the difficulties and achievements) the needs of the client, family and carer are more easily obtained.

Possibly the biggest challenge is finding a carer with the correct skill set and personality traits to provide the necessary care with a caring manner. Your needs may be very specific and you need to ensure that the carer's skills match those needs. Don't be afraid to ask to see qualifications, but actions are also needed to back up that piece of paper. If they are qualified for ventilators let them show you how, and what they do if things go wrong! Ask them to show you how they do transfers, give them specific scenarios and problems to solve. Acknowledgement, and a little praise, goes a long way toward enhancing further client care.

Medicalschemes often require additional information before making funding decisions. Thiscould include the clinical report of the injury and the requirements includingphysical assistance, equipment and medical care. They may even ask for anestimated cost and duration of the HBC.

The Department of Social Services distribute food parcels to people with disabilities who are waiting for their grants to be processed. This excludes care services. Many NPOs and NGOswho provide functional HBC to people with TB and HIV extend their services to people with disabilities. Speak to health professionals and clinics in your area to find out more.

In the next few years there will be changes to government Primary Health Services and each municipal ward should have a team of community healthworkers. They will do home visits and provide basic care where necessary. Pilot programmes are already running.

What must I ask myself?

Is HBC the best option?

What HB care do I need? What hours? How long willI need HBC?

Which are essential services and which nice-to-have?

Once the HB carer begins ask yourself:

Do they have the skills and training to fulfil myneeds?

Do I like this person and will I be able to trustthem?

What must I ask the agency?

Which areas do you work in?

Is there a needs assessment before placing staff?

Do you have a BHF number, and are qualified carers registered with SANC?

What supervision do staff receive?

Do you provide on-going staff training?

What professional support does the agency provide to the carer? How is this measured and how are agency staff held accountable?

What is the line of communication once you have placed a HB Carer?

What happens if the HB Carer is ill, or has trouble getting to work?

Recent references of the carer.

How do I request a different HB carer?

Must I sign a fixed period contract?

ALWAYS:

Have a written and signed contract.

READ THE SMALL PRINT.

Double check recent references- phone them!

Have a trial care period during which either party can back out.

Work on establishing trust with the carer.

Communicate openly and regularly.

My sincere thanks to all who contributed to this article, both carers and cared for!